8528 Background: To explore the underlying biology in young patients (pts) with non-small cell lung cancer (NSCLC), we analyzed the genomic diversity of serial circulating tumor DNA (ctDNA). Methods: We analyzed ctDNA data from a national database Guardant Health NGS panel of 83 loci from a population of 5210 NSCLC pts between the ages of 18-50 collected between 1/20-6/2020, with longitudinal samples from 931 pts (2 samples), 286 pts (3 samples), and 166 pts (> 3 samples) with at least 90 days between the first and last sample. We evaluated statistical significance using Spearman correlation, the Mann-Whitney U test, the signed-rank test, or Fisher’s exact test. We used Gene Ontology enrichment analysis and Ingenuity for genomics and MetaboAnalyst for metabolomic pathway analysis. Results: Out of 5,210 young adult (YA) NSCLC pts, 6,624 liquid NGS tests were conducted, of which 9% of pts were between 18 and 35 years old, defined as very young adults (VYA), and 91% were between 35 and 50 years old, defined as young adults (YA). Overall, mutation frequency increased significantly with age (Spearman r = 0.08, p = 1.9 · 10-10). Most pts were female (2,826, 54%).Mutation frequency was higher in males (Mann-Whitney p = 1.8 · 10⁻⁵). The rate of targetable alterations was 48% in YA and 46% in VYA-NSCLC patients, with EGFR being the most common alteration (24% in YA, 18.4% in VYA). Of the 13 genes with mutation frequencies of at least 5%, there are 11 genes with more alterations in males and 2 in females. Immune-related pathways were infrequently altered (4.8%), while TP53/DNA damage (50%), EGFR/RAS (30%), PI3K (35%), and β-catenin/APC (28%) pathways were frequently altered. Endocrine resistance pathways altered second most (p=0.03), likely due to distinct biology or treatment effects. Metabolomic analysis identified methylation-related pathways (28.6%), including MAT1A, as the most prominent metabolomic pathways (p = 0.02). Longitudinal analysis revealed increased ctDNA burden with tumor progression. Comparing the first-to-last ctDNA in the same pts, we identified genes with distinct patterns of alteration in YA and VYA pts (Tab-1). TP53 and EGFR remain highly mutated but with stable mutation rates (TP53: 51% to 52%, EGFR: 41% to 41%). Conclusions: Targetable alterations are highly prevalent in YA and VYA NSCLC, exhibiting distinct ctDNA mutation frequencies upon serial testing. DNA methylation can potentially regulate gene expression in metabolic pathways, suggesting therapeutic avenues. Highest positive and negative changes in mutation frequencies from first to last sample in YA and VYA NSCLC using Guardant serial ctDNA. Genes in 1st and last sample(Difference range) Young (35-50 Yo) Very young (<35 Yo) Uncorrected Signed Ranked Test P-Value Rise in mut freq.KRASMETBRAFAPCDecline mut freq. in at least one groupPIK3CABRCA2 MYC 0.350.650.500.160.560.081.0 0.250.160.600.33-0.25-0.20-0.20 0.010.000.080.330.010.750.08
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